Week 22, 26 May – 1 June 2018

General developments & political & security situation • Overall security situation remains volatile and unstable with the main hot spots in areas of , Raqqah, and Al- towns. There is a trend of increasing number of asymmetric attacks in the North-Eastern and North regions, particularly in rural areas of Deir Ez-Zor, Ar-Raqqah and Governorates. • In northern Rural , Armed clashes continue with increased artillery shelling and airstrikes against towns controlled by NSAGs, mainly Al-Latamneh, Al-Zakat, Kafer Zita and . • It is likely that southern is the coming target of military operations by the Syrian Arab Army. Daraa remains volatile and unstable, sporadic clashes and indirect fire exchange are still taking place in Daraa Al- Balad and Al-Mahatta neighbourhoods of Daraa City as well as several towns of Daraa governorate. • Evacuation process of the NSAGs in South , north rural and south rural Hama has concluded.

OVERVIEW KEY HEALTH ISSUES Health response to multiple and simultaneously evolving emergency situations across the country: • Cases of measles across the country, leishmaniasis in northern Syria and acute diarrhea in NE Syria. • Responses to displacements from Afrin district (137,070 individuals Tall Refaat, Nabul, and Fafin areas), in East Ghouta (approximately 44,000 IDPs remain in 8 shelters and an estimated population between 100 and 140,000 in the communities), in northern rural Homs 150,000 people remain in areas largely inaccessible to health assistance.

KEY GAPS & CHALLENGES • Lack of information or access to areas recently regained by GoS. • Little known about the status of public health care facilities in the areas occupied by the Turkish government and the Kurdish Self-Administration.

OPERATIONAL UPDATES

1. Coordination: • Conducted national level health working group meeting (29 May). Among other issues, ongoing emergency preparedness and response activities to , North-East, Damascus/Yarmouk, Southern Damascus, Northern rural Homs, and eastern Ghouta are being coordinated. • As part of HPC (Humanitarian Program Cycle) 2019, the health sector questionnaire for MSNA is revised. • Health sector is ready to participate in the MoFA’s approved IA convoy plan for May – June. A total 808,050 of the 860,200 requested beneficiaries (93.94 %) in the May - June plan were approved: 470,250 were approved in full, and 337,800 approved with conditions. Of the 20 requests, eight were approved in full (40 %) and 12 were approved with a lower PIN or the PIN will have to be confirmed (60 %). • Health sector looks as one of the priorities to provide support to 48 locations approved by MoFA outside the plan: 25 locations in Damascus and Rural Damascus; six in Aleppo; two locations in Deir-Ez-Zor, two locations in Daraa, one location in Hama, seven in Homs, and five locations in .

2. Information and planning: • 4 infographics of summary of key performance indicators for April 2018, across Syria; North-east Syria; North- west Syria; Southern Syria • Health Sector 4Ws Snapshots for April 2018 across Syria • Started using Surveillance System for Attacks on Health Care (SSA) developed by HQ for MVH reports • Started the first stage of national health information system in Syria for primary health care in MoH

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• Attended the extended pillar groups meeting with government counter parts to discuss the 2017 SF reporting and 2018/2019 pillar groups workplans. • New maps: - WHO-Supported Facilities in NES; - Distribution of AD cases in Deir-ez-Zor governorate as of 23 May 2018; - Distribution and functionality status of public health facilities in Mubadaret Ahl AlSham, Damascus; - Revitalized Nutrition Surveillance Centers in ; - Distribution and EWARS Sentinel Sites in Homs governorate.

3. Health operations:

Aleppo & Afrin response: Situation update • No major changing in situation is the reporting period • Despite returning movement reported from GoS areas to NSAGs areas through Ibin village crossing point, an estimated 137,070 people remain displaced. NGO activities • 13 NGO-supported medical mobile teams and 1 NGO-supported public health clinic provide essential health care services. 6 mobile clinics and 6 health facilities (DoH/SARC) have been mobilized for the Afrin response. 7 NGO-supported medical mobile teams are in the pipeline to enhance the response. • 3587 outpatient consultations were provided, as the service is available on daily basis to Afrin IDPs. See Annex 5 for breakdown. Nutrition activities: • 10 WHO supported nutrition surveillance teams run their activities in Afrin IDPs sites. • 639 children under 5 years screened during this week • See Annex 6 for breakdown. Mental Health • 581 MHPSS and medical services have been provided through the 13 WHO Supported mobile teams Medical transportation for critical cases • Ongoing coordination between SARC, DoH, and WHO to enhance the mechanism to transport critical cases. • 3 critical cases were transported by SARC to Aleppo University Hospital, in addition 4 cases have been referred to Zahraa local hospital. Response to students from HTR for national exam: • WHO through partnership with five national NGOs response to the health needs of 1500 high school students coming from HTR areas.

East Ghouta response According to UNHCR, 13,499 people left shelters since 15 May. WHO is part of UNHCR coordinated Collective Shelter Coordination and Management Structure. • All 8 shelters are covered by fixed and mobile teams providing ambulance/emergency services, OPD, RH and child, and mental health services. • Health sector partners are to continue using “Health services Assessment Tool - Shelter/Camp”. • A special focus is made on balancing the operational presence and continuous coverage of remaining IDPs in shelters considering the daily returns to various locations in eastern Ghouta. Challenges in shelters: • Absence of patient health cards, prescription of medicines. • High utilization rate of health services with continued high number of consultations per team per day. • Referrals of non-life threatening conditions limited. Need for dentistry and x-ray services. • Increasing number of children identified in need of mental health support (e.g. enuresis). • There are a high number of children detected with prosthetic related problems (e.g. amputations). 2

• A number of detected cancer patients are not being able to be hospitalized for required treatment. • Reporting shortages of medicines and some of health supplies. • Receiving approvals for referral of patients outside of shelters. A separate analysis is required on the originating shelters for all referrals. Challenges inside eastern Ghouta: • Only a few partners have received approvals to work across eastern Ghouta. No access by UN agencies to date with the exception of one IA assessment mission to Kafr Batna and Saqba on14 May. • A joint WHO, SARC, MoH in-depth public health assessment is still pending. • Necessity to revitalize non-functioning health facilities across the area. Understanding the GoS plans to integrate clinics/hospitals in the public health system.

Homs response: Response to Northern Rural Homs • On 30 May, WHO distributed 4 tons of medicine and supplies (16,642 treatments and 200 trauma cases) to and Tlol Alhomor as part of an interagency convoy. • DoH vaccination program vaccinated 299 children <5 with OPV, and 259 drop-out children from routine vaccination at 4 PHCs (Talbiseh, Rastan, Ghanto, Dar Kabira, ). Coverage for the routine vaccination from this sample is approximately 13%. Routine program • Field visit was conducted to the Al Andalus shelter supported by Shabab Al Khir Society to distribute Permethrin 1% Shampoo for 34 families. • Follow up for WASH project with DOH Homs in and Fairozah , 2 villages east Homs, water samples were taken for the chemical and biochemical analysis. • Annex 4 contains number of beneficiaries of Albir NGO- WHO partner in Homs.

Lattakia response: • Conducted the following trainings at Lattakia & Tartous DOH, baby Friendly Hospitals (BFH), Basic Trauma Life Support “BTLS”. • Delivered 8 mobile clinics in favor of MOH. • Distributed Posters and Flyers to Local NGOs for the “World Smoking Day” event.

Northeast Syria (Al-Hassakeh; Ar Raqqa; Deir-ez-Zoir) response: Coordination • Conducted meetings with Al-Hasakah governor, UNFPA CO staff and head of UNHCR • Follow up visit on TB in Roj camp. Acute diarrhea in Dier Ezzor: • Acute diarrhea cases have been reported to WHO from Deir Ezzor Governorate in north eastern Syria since 26 April. Several villages on the eastern bank of the Euphrates have reported cases. • 28 cases including 5 deaths have been reported to WHO from health facilities. As per their most recent update on 29 May 2018, KRC have reported 391 cases and 2 deaths of acute diarrhea. • Lab results of (21) stool samples tested by MoH, 16 samples tested positive and 5 tested negative all samples indicated that E. coli as the predominant etiology, lab tests to identify E. coli O157:H7 were negative. • Lab results of (14) stool samples tested by Kurdish Red Crescent were negative for shigella and salmonella. Pharmacy and STHC program: • 1 ton of health supplies to support Qamishli hospital including :Ventilator, Gynecological bed, Anesthetics, IV fluids and consumables • 0.5 tons of health supplies to support the needs of Allulua hospital, included sterilization laboratory equipment, stretchers and examination bed, IV fluids and consumables. • 21,500 treatments of CDs, NCDs and Mental Health Medications distributed through KRC medical points to Alreesha, Alhol camps and Ar-Raqqa city 3

• 5 burn kits and topical antimicrobials distributed through a health actor to support the burns unit in Al- Hassakeh hospital. • Lab equipment distributed through a health actor to support Tal Tamr hospital. National NGOs coordination: • St. Ephram committee in coordination with three NGOs, GOPA and Al-Hikmah private hospital are the ongoing WHO’s partners. • Launched health and community center in Al-Hasakah city and the Static medical point in Al-Areesha camp. • Coordinated to support the Static medical point in Al-Areesha camp with the needed medicines. • Coordinated and follow up 3 cases referred from Tal Abyad to Al-Hikmah hospital. • Annex 5 contains number of beneficiaries of partners in NES.

4. Technical Expertise

Non-Communicable diseases / Primary healthcare • Under Biennium program 2018-2019; conducted a Tobacco Control TOT workshop 27-29 May, targeting 25 doctors & directors of Tobacco control program in DOHs from Rural Damascus. • Held follow up meeting with the director of the Regional Center for Training & Oral Health Research / MOE , to discuss detailed action plan to cover oral health services for school students & children residing in IDPs shelters from EG & newly accessible towns inside EG.

Immunization: • No update. • See Annex 2 for capacity building activities this week

Mental health program: • Site visits were conducted to 7 PHC and community health centers in Hama, As-Sweida’a and Damascus. • Meeting of MHPSS TWG chairs to discuss the range of options in relation to ground needs and entry points for MHPSS.net. • Coordination with MoE authorities to follow up on the implementation of the WHO EMRO School Mental Health Programme (SMHP) and the way forward. • See Annex 2 for capacity building activities this week

Nutrition and child health: • Conducting a data Survey concerning the admissions on Stabilization Centers for March 2018. Among 19 activated Stabilization Centers, there were 63 admissions, with the highest number was in Lattakia: 14 admissions (22.2 %).

Secondary health care program: • Delivered about 19,142 treatments of life saving and essential medicines and medical supplies including IV fluids, antibiotics, anesthetics, and hemodialysis sessions to Al Hassaka, Ar-Raqqa, Hama ,Homs, and Aleppo. • Medical equipment distributed to different health facilities in Al Hassaka and SARC in Homs.

Trauma: • Coordination with MOH to increase provision of reproductive health services in the PHC centers in the area south of Ar Raqqa (namely: Maadan, Ghernata, Al Hamadaniya and Sabkha centers). • WHO distributed supplies to the University Maternal Hospital in Aleppo, including 2 operating tables, an infant incubator and operating theatre ceiling lights. • WHO distributed a defibrillator and monitor to the emergency department at Al Mwasat Hospital (MOHE) in Damascus.

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• See Annex 2 for capacity building activities this week

Disease surveillance and response: • See Deir-Ezzor diarrheoa in NES section. • See Annex 2 for capacity building activities this week.

WASH • Water quality monitoring in: - 8 East Ghouta camps is in progress is in collaboration with SARC. - NES camps in progress is in collaboration with UNICEF and UNHCR. Detailed discussions are ongoing with NES WASH coordinator to ensure that disinfection of Jerry cans is given proper priority. - Northwest Syria camps (Afin IDP camps) is in progress in collaboration with SARC. - Uncontrolled sources in Aleppo is in progress in collaboration with Directorate of Environment, Directorate of Health, Directorate of Water Resources and Aleppo Water Establishment. - Homs for reservoirs and groundwater wells is in progress. DoH has monitored over 350 water supply sources to date. • Medical waste trucks and 300 waste bins for Damascus Waste Directorate will arrive mid-July 2018. • Procurement of 450 medical waste bins for DoH Aleppo will arrive to Lattakia warehouse by mid-June 2018.\

National NGO coordination: • The first training workshop on infection control has been conducted in coordination with MOH for DOH and NGOs health workers in EG IDPs shelters and Eastern Ghouta. • The preliminary phase of data collect to update the data base of affiliated health facilities to NGOs has been completed , training workshop on new HeRAMS reporting mechanism will follow by mid next month. • Current NGO MoUs in Annex 1

External Relations, Coordination and Communications: • Coordination with Japan for funding support under the upcoming Japan Supplementary Budget (JSB 2018) • Submitted 1st feedback to SIM (DfID third party monitor) on the report of the site visit to Tal Abiad hospital. • Official meeting held between WR and the deputy Minister of Health. The meeting concentrated on the GPW13 and PB 2020-2021 as well as on the joint cooperation between WHO and MOH to support the re- instating of health services in East Ghouta communities. A NV was sent to MoH in this regard requesting the holding of an official meeting with all concerned parties. • Official communications with MoFA to follow up on the joint WHO and the Japanese delegation field visit to Harasta Hospital and the Pediatric hospital: proposed on 4 June 2018. • Disseminating different educational media materials (250 posters and 1000 flyers) distributed to the sub offices, NGOs , partners and sister UN agencies to demonstrate the WHO World No Tobacco Day 2018 . • WHO-Syria Twitter account: several tweets about WHO interventions and health response.

Operational support and logistics: • Dispatched 75.8 tons of medical & nutritional supplies, health kits and printing materials, covering 10 governorates (Aleppo, Rural Damascus, Damascus, Raqqa, Homs, Hama, Deir Ez-Zor, Al-Hasakah, & Daraa). The recipients included 13 MoH facilities, KRC, SARC, and nongovernmental hospital. • The total number of treatments is 104,447 and 550 trauma cases. The dispatched supplies included: - 30 MUREX HIV Ag/Ab Combination Kits delivered to MoH – Public Health Labs – Polio Lab. - 252,300 Natural breastfeeding flyers delivered to MoH central warehouse in Damascus in favour of MoH – Nutrition program. - Different types of nutrition equipment delivered to Aleppo, Al-Hasakah, Daraa, Deir Ez-Zor, Hama, Homs, Quneitra and rural Damascus DoHs and MoH central warehouse. 5

- 8 mobile clinics were handed over to MoH in order to be functioned in Aleppo, Homs, Hama, Daraa, Rural Damascus, Al-Hasakah DoHs and 1 national NGO in Aleppo. - 1 Autoclave, 1 Dry Heat Sterilizer, 1 Examination bed, 1 WNB water bath, 1 Isotherm Forced Convection Incubator (54 Liters) and different types of trauma and STHC medicines delivered to MoH – Al-Luluwa hospital in Al-Hasakah. - 1 adult ventilator, 1 delivery bed, 1 major surgical kit and different types of trauma and STHC medicines delivered to Qamishli national hospital in Al-Hasakah. - 50 children body bags, 200 Fresenius haemodialysis sessions, 1 ultrasound gel container, 5002 bottles of benzyl benzoate delivered to MoH - Tal Abiad national hospital in Raqqa. - 1 Vitalograph ALPHA spirometer, 3 WNB water baths and different types of EWARS, mental health, STHC, PHC and trauma medical supplies delivered to KRC in Al-Hasakah. - 500 ampoules of Meglumine antimonite 1.5 g/5 ml and 100 adults Fresenius haemodialysis sessions delivered to Kobani nongovernmental hospital in Aleppo. - 100 adults Fresenius haemodialysis sessions, 1 Italian emergency kit B, 1 Italian emergency kit A, 3 IEHK supplementary kits and different types of EWARS, PHC, STHC and trauma medical supplies delivered to Aleppo SARC. - 1 mobile x-ray, 2 Italian emergency kits B, 1 delivery bed, 1 examination bed, 2 adult sphygmomanometer cuff and different types of EWARS, nutition, PHC, STHC and trauma medical supplies and printing materials delivered to Talbissa and Tlul Al-Homor in both Homs and Hama as an IA convoy through SARC support.

RESPONSE PRIORITIES - Afrin, Eastern Ghouta, Rural Homs, North-East Syria.

Annex 1: Current WHO agreements with national NGOs

# ongoing # in Governorate Location of current of ongoing MOUs MOUs preparation

Damascus Dummer Al Balad - Al Midan - 4 4 Dahyet Qudsayeh - Hai Al Wourood - Bludan, Madaia, Sargayah, Sasaa , Kharbet Al Ward, Rural Damascus Kharbet Al Shaiab 2 2 EG Response Herjaleh, Harasta, Kfer Batna, Ein Terma 3 3 Homs Wear, Al Hamra, Al Hamediayeh ,Al Qaryatain, Al Fruklus 1 5 Hama 0 3 Nabul - Zanairta - Mayasah - AL-Mogambo - Burj Al-Kaaf -Al-Zouk - Tall Refaat - Kafar Naya - Al-Zyara - Deer Jmal - Ihras - Kashtaar - Al-Ukaibeh - Kherbat AL-Hayat - Tal Aleppo Jbeen - Ibeen - said - Salah AL-Deen - Al-Mshatia - Bostan AL-Zahra - Al-Villat - Menbej 3 5 Al Hasakeh Hasakeh city - Mabroukeh camp 3 2

Ar Raqqa Al-Tabqa - Al-Twehena camp - Ain Issa campAl-Karama/Alhamrat 1

Deir Ez zor Deir Ez zor city + Abu Khashab 1 1 Total 18 25

Annex 2: WHO supported capacity strengthening (10 activities for 255 participants.)

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# Date participan Details/Field Program ts

27-28/05/2018 25 Surveillance teams in Damascus PHC

27-31/05/2018 25 School Mental Health Program for MoE of R. Damascus in Damascus MH

27-28/05/2018 25 Psychological First Aid "PFA" and Self-care strategies for MoH of Homs-Nurses in Homs MH

27-25/05/2018 25 Disability Management in Damascus Trauma

27-29/05/2018 25 Hospital Major Incident Medical Support “HMIMMS” in Damascus Trauma Mental health GAP intervention guide phase1 for UNRWA & NGO from Damascus and 27-31/05/2018 25 MH R. Damascus in Damascus

29-31/05/2018 25 Surveillance program workshop for Surveillance officers - Part 2 in Damascus PHC

29-31/05/2018 30 Prevent HIV transmission from pregnant mother to fetus in Daraa governorate, in Daraa EWARS 2 Psychological First Aid "PFA" and Self-care strategies for MoH of Daraa-Nurses in 30-31/05/2018 50 MH Damascus and Aleppo

27-28/05/2018 25 Surveillance teams in Damascus PHC

Annex 3: WHO Supported Health services in NES

# of # of Mental # of # of secondary # of # of assisted beneficiaries Health Governorate Area outpatient health trauma people with reached with Psychosocial consultations consultations referrals disability the medicines Services Al-Hasakah Hasakah city center 784 605 73 45 179 2

Al-Hasakah Al-Areesha camp 25 0 0 0 47 0 0 Al-Raqqa Al-Tabqa 228 228 0 19 0

Al-Raqqa Al-Twehena camp 190 190 0 0 45 0

Al-Raqqa Al-Karama/Alhamrat 114 114 0 0 5 0

Deir Ezzour Deir Ezzour city 465 344 0 0 46 0

Sub-total: 1806 1481 73 45 341 2

Annex 4: WHO Supported Health services in Homs

# of outpatient # of SHC # of trauma Partner District Commune/Village/Town consultations PHC services patients services Alhamra clinic Homs city 3457 193 Alhamra clinic AL-Birr

AL-Birr ALWaer clinics ALWaer 1877 186 ALWaer clinics Furqlus village 768 97 Furqlus AL-Birr AL-Birr Qaryatayn Qaryatayn village 506 119 Qaryatayn

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Hamediyeh clinic Homs city 2944 155 Hamediyeh AL-Birr clinic 9552 750 Sub-total:

Annex 5: Health services provided through national NGOs health facilities to Afrin IDPs

# of patients # of outpatient received #of MHPSS # Partner Health facility District consultations PHC assistance with services services medicines

Al-Ihsan Meskaan-Kafr Naseh 158 114 98 1 Mobile team

Al-Ihsan Mobile team 67 306 69 2 kafen

Al-Ihsan Mobile team 73 181 158 3 Abin Mobile team 98 140 78 4 Al-Ihsan Kishtaar – Tenib

Mobile team Kherbet Al-Hayat 196 284 5 Yadan Biyad

Mobile team Zyara 455 406 6 Yadan Biyad

Mobile team Fafin Camp 386 362 7 Yadan Biyad

Mobile team Tall Shuair 550 529 8 Yadan Biyad

Mobile team Afrin Camp 68 93 39 9 SCC

Mobile team Al-Asser Camp 245 80 41 10 SCC

Al-Taalouf Mobile team Al-Aloushiya camp 117 108 11

Al-Taalouf Mobile team Al-Ukaiba 115 103 12

13 GOPA Mobile team Al-Shahbaa camp 45 39 98

+1 Al-Ihsan PHC Nubbol 1014 987

Sub total 3587 3732 581

Annex 6: Nutrition surveillance activities in Aleppo for Afrin IDPs

MUAC <12.5cm but MUAC <

MUAC > 12.5 >11.5cm 11.5 SAM Locations NGO Health facility Normal Cases cases Green MAM Cases Yellow Red Male Female Male Female Male Female Al-Ihsan Nubbol PHC 47 39 Charity

Kafen ,Meskaan Mobile team 48 58 1 Al-Ihsan

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Charity

Al-Ihsan Kafr Naya , Burj , Al-Zouk Mobile team 69 33 1 Charity

Al-Ihsan Deer Jmal Mobile team 39 22 Charity

Al-Ihsan Kishtaar , Tenib Mobile team 47 38 1 Charity

Fafin Camp YBY Mobile team 29 17

Tall Shear YBY Mobile team 22 33 1

Al-Asser Camp SCC Mobile team 27 33 1 1

Al- AL-Ukaiba , Al-Aloushiya , Tall refaat Mobile team 6 5 Taalouf

Sub total 453 372 3 3 0 0

Annex 7: Number of health services provided through national NGOs health facilities under regular program in Aleppo:

# of outpatient consultations # of patients received assistance # NGO Collective shelter PHC services with medicines

1 Health promotion Al-Fatat Al-Arabieh 189 89

2 Health promotion Zahrat Al-Madaaen 68 163

3 Al- Beer & Al-Ihsan Fanon 10 187 85

4 Al- Beer & Al-Ihsan Rahmo AL-Hatab 86 57

5 Al-Ihsan Tawfek Oulabi 69 44

Total No of services provided for students from HTR areas this week 438

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